[Pancreatic fractures: the role of CT and the indications for endoscopic retrograde pancreatography].
OBJECTIVE
To assess the role and the diagnostic yield of CT and of endoscopic retrograde cholangiopancreatography (ERCP) in the study of emergency pancreatic injuries from blunt abdominal trauma.


METHODS
January, 1992, to December, 1996, eleven subjects with pancreatic trauma were operated on. The patients were 8 men and 3 women (mean age: 28.4 years, range: 15-47 years) with pancreatic traumas of different severity but all with gland fracture and severe ductal injuries. Direct radiography was performed in all cases in different projections: CT with 1 cm slice thickness and feed was also performed. A contrast agent was administered orally in 8/11 patients and i.v. in 11/11. ERCP was performed in supine recumbency within 12 hours of trauma; a hypotonic agent was administered i.v. in 5 cases. The examination was successful in 10 patients. Wirsung duct studies were extended to the biliary tract in 6 cases.


RESULTS
Pancreatic traumas were never isolated and usually associated with other abdominal injuries in the liver, spleen, small intestine, kidneys (by frequency) and with injuries in other body regions--the chest in 8/9 cases, limbs in 7/9, the spine in 4/9 and the skull-brain in 3/9 cases. Pancreatic fractures were mostly cervical and 3 of them were bifocal. The radiologic findings of pneumoperitoneum (4 cases), sentinel loop (3), paralytic ileum (11), air-fluid levels (9) were always aspecific. CT had 66.7% sensitivity, with over-all accuracy of pancreatic involvement by trauma in 5/11 cases and specific findings of fracture in 1/11 cases. CT showed associated parenchymal injuries in both the abdomen and other sites. ERCP diagnostic accuracy and sensitivity topped 100% in the demonstration of ductal injuries.


CONCLUSIONS
Pancreatic traumas are usually a rather uncommon event. They are classified as major and minor according to the extent and severity of ductal involvement. Injury site corresponds to the direction of impact force, but the neck is the preferential site for fractures because it is compressed within the spine and extended. Clinical findings are usually aspecific and questionable and diagnostic imaging, especially CT, plays therefore a major role in treatment planning. However, CT provides mainly indirect signs and fails to depict ductal rupture. Despite its difficult technical execution in emergency, ERCP shows ductal injuries with extreme accuracy and specificity, which finding is indispensable for treatment planning.


CONCLUSIONS
Both CT and ERCP are necessary tools to diagnose pancreatic fractures: the former because it provides indispensable panoramic findings and the latter because it is the only method showing ductal involvement. Therefore, both techniques should be used for accurate surgical planning, which is a crucial step for the prognosis of these injuries. Cost-effectiveness and safe execution are well balanced.
Coppola
V
V
Istituto di Scienze Radiologiche, Università Federico II, Napoli.
Vallone
G
G
Verrengia
D
D
Di Filippo
G
G
Alfinito
M
M
Coppola
M
M
Alfano
L
L
Smaltino
F
F
D000007:Abdominal Injuries / Q000000981:diagnostic imaging; D000293:Adolescent; D000328:Adult; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods; D003287:Contrast Media; D004630:Emergencies; D005188:False Negative Reactions; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000000981:diagnostic imaging* / Q000293:injuries*; D012421:Rupture; D014057:Tomography, X-Ray Computed / Q000379:methods; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging
D003287:Contrast Media
Fratture del pancreas: ruolo della TC e indicazioni alla pancreatografia retrograda endoscopica.